The Ethics of Public Health

Mr. Chaim Ramon

Minister of Health

The Ethics of Public Health

I am pleased to welcome you all to this International Conference on Medicine, Ethics and Halacha, which is taking place under the auspices of the Dr. Falk Schlesinger Institute for the Research of Medicine according to Torah, at the Shaare Zedek Medical Center in Jerusalem and in conjunction with the Albert Einstein School of Medicine in New York.

Often decisions on the ministerial level which I must take involve matters of halacha, and I say this with full recognition of the significance of the issue. During recent years the Israeli public has become more aware of the importance of the subject of medicine, ethics and halacha. Today there is greater understanding of the importance of ethical and moral perspectives on medical treatment, and particularly on sophisticated, modern treatment.

There are some ethical decisions to which little attention is paid. For instance, the ethical decision as to the minimum weight of a premature baby which justifies resuscitation. Until recently, a premature baby weighing six hundred grams had a definite death sentence. There was simply no chance of its surviving. Today, babies weighing six hundred grams can live, and it is standard procedure to resuscitate them.

Now, we know that some of them will not lead normal lives. And the ethical question is whether we should resuscitate premature infants weighing six hundred grams, despite the chances that some of them will lead very handicapped lives, almost without any relief. Should we nevertheless apply resuscitation techniques to all of them for the sake of the others, who will lead normal lives?

And a more serious question: What if tomorrow a doctor decides to resuscitate an infant weighing four hundred grams, while today some 80% of such infants remain handicapped for life? Shall we allow this resuscitation or not? These are questions which I lay before doctors, because no Minister of Health anywhere in the world would presume to come to a doctor and tell him, “Let this one live, let this one die.” And on the other side of the scale: You see a very elderly person, terminally ill with no hope, and yet he continues to be treated both conventionally and surgically. Who is to decide?

An interesting experiment was carried out in the State of Oregon in the USA: A public committee made up
of representatives of different disciplines, including a priest, a legislator, a politician, a lawyer, a jurist and an economist, arrived at a long list of treatments and conditions which the State was obligated to cover. As to those conditions not included in the list, they decided that a person who had sufficient funds at his disposal would be entitled to pay and receive treatment. If we return to our example of the babies, someone who had enough money could receive resuscitation for a six hundred gram baby, while the State would cover and grant life only to infants weighing over a kilogram.

In the wake of this experiment, several articles, heavy with criticism, appeared in the American press. The most famous article appeared in the New York Times, entitled “Oregon is playing G-d.” My own conclusion is that these decisions are very complex and complicated.

We know from economic experience that 80% of a person's medical expenses are accumulated during the last two years of his life. And out of this 80%, a considerable percentage is spent on his last two or three weeks. Then, when we are faced with a shortage of resources and I have to decide how to contribute to raising the level of preventive medicine and how to allocate funds towards inoculating the public against meningitis, I find myself in a dilemma. Do we refuse the last two weeks of
treatment for these elderly people and invest these resources in babies, children and mass immunization, knowing that they will have better and longer lives?

I have touched on a tiny sample of ethical questions which are involved in daily life. I am happy to note that it is not only in Israel that we grapple with these problems.  It is a pleasure to see such a large number of participants from all over the world. I believe that Torah truly can and must "come forth from Zion." I am indeed pleased that the conference is taking place at the Shaare Zedek Medical Center, a modern, well-equipped hospital, managed according to principles which we are trying to introduce in other hospitals in Israel, a hospital which conscientiously integrates halacha in its medical activity with great success. Shaare Zedek Medical Center is considered today as having among the highest medical standards in the country, proving that halacha can be integrated with modern medicine without compromising either halacha or medicine. The result allows for good service for the public – secular and religious, Jews and Gentiles alike. All receive treatment of a high standard and with a feeling of comfort within the institution.

I thank all the participants in the conference and wish you, on behalf of myself, the Ministry of Health and the Israeli government, productive sessions and much success.